JOINT BUSINESS REGISTRATION FORM

Transcription

1 WY1C1WC (04/2007) Expires 09/30/2007 WYOMING DEPARTMENT OF EMPLOYMENT Unemployment Insurance and Workers Compensation JOINT BUSINESS REGISTRATION FORM The Wyoming Department of Employment is pleased to present this joint application form, which enables you to apply for required Unemployment Insurance and Workers Safety and Compensation business accounts by completing one form NOTE: A person who knowingly or with deliberate disregard of the facts or the requirements of the Wyoming Employment Security Law or the Wyoming Workers' Compensation Act, violates or attempts to violate or who knowingly advises another to violate these Acts related to determining the assignment of a contribution rate shall be subject to civil and felony penalties punishable by a fine of not more than $50,000, imprisonment for not more than 5 years, or both. Processing will not begin until we receive the signed paper copy (see signatures on page 4). Allow a minimum of three weeks for processing. Incomplete applications will be returned, causing further delay and potentially severe penalties. Faxes will not be accepted. Mail the completed application to: UNEMPLOYMENT TAX DIVISION EMPLOYER SERVICES P O BOX 2760 CASPER WY 82602

2 A Return Completed Form to: JOINT BUSINESS REGISTRATION FORM Employer Services PO Box 2760 Casper WY INTERNET For information call Unemployment Insurance (307) or Workers Compensation (307) Legal Business Name: (Name of the sole owner, partnership, corporation, limited liability company, governmental entity or other.) 2. Doing Business As: (d.b.a. - the name you present to the public, if different than #1.) 3. Addresses Street or P. O. Box City State Zip Mailing address Tax Forms: Primary Office address: For Unemployment Claims: For Workers Comp Claims: 4. Work Locations/Physical Locations in Wyoming. Physical location of all business operations in Wyoming (i.e., office street address; location of a job site; address of employee working out of his home; sales representative location). List principal business location first and attach additional sheets if necessary. a. Street Address (NO P.O. BOXES) City In Wyoming County Zip Phone Number and Location Type (i.e., office; home; job site) Loc Type: Phone: b. Loc Type: Phone: Do your Wyoming based employees also work in other states? Yes If yes, list those states: 5. Contact Person and Business Telephone Number: (Individual(s) authorized to provide and receive information about your account.) For Unemployment Insurance: For Workers Compensation: 6. Type of Ownership: (Check only one.) Contact Name Phone Number Fax Number (optional) Sole Owner Corporation State where incorporated: n Profit Corporation Government Partnership Limited Liability Company Do you wish to have Unemployment coverage for your LLC members? Yes Other (describe): Page 1

3 7a. Reason for applying: New Business (Continue with question 8.) We have an existing Unemployment account and are now requesting Workers Compensation coverage. Provide your Unemployment account number: (Continue with question 8.) Change of Entity - example: change from sole owner to corporation (Continue with question 7b.) Reorganization (Continue with question 7b.) Acquired/Purchased an existing business (Continue with question 7b, and complete page 5) Merger (Continue with question 7b. and complete page 5) Other (describe): 7b. Information about the previous business: Business Name: Owner's Name: Federal Employer Identification Number (FEIN): Unemployment Account #: Workers Compensation Employer #: What percentage of the business did you acquire? Did you own an interest in the previous business? Date of acquisition: 8a. Date you first hired or expect to hire employees in Wyoming: (Excluding Corporate Officers and LLC Members) (Required) 8b. Date you first paid wages to employees performing service in Wyoming: (Excluding Corporate Officers and LLC Members) 8c. Will corporate officers receive compensation or salary? Yes If yes, beginning on what date: Will you be using an Employee Leasing or Professional Employer Organization? If Yes, What is their business name and UI account number? 9. Estimated Total Monthly Payroll (Wyoming wages only): $ Yes 10. Identify all owners, partners, corporate officers, trustees, or members: Name Title Social Security Number % of ownership State of Residency Date Residency Established 11. Federal Employer Identification Number (FEIN) as assigned by IRS: (If you do not have an FEIN at this time, leave this space blank and submit your FEIN to the Division once you receive it.) 12. Are you covered by the Federal Unemployment Tax Act (FUTA)? (Information on whether you are liable for FUTA can be obtained by contacting the IRS.) Yes Page 2

4 13a. Provide detailed information about the primary nature of your business in the description area below, including your business activities, goods, products, or services in Wyoming, as though you were telling a prospective employee what you do. Then give us the approximate percentage of sales or revenues resulting from each item. Percentages should total 100%. If you are a third party agent for the business, such as a payroll service or accountant, please review this item with your client. Examples follow: Goods or Products: What are they, and what do you do with them? Do you design, manufacture, sell directly to consumers, distribute to wholesalers, install, repair, or do something else with them? What are these goods or products made of? Example 1: Major appliances: Sell to public 40%; Sell to retailers 30%; Repair 30% Example 2: Install fiber optic cable 100%. Example 3: Merchant Wholesaler: Industrial Supplies 100% Example 4: Manufacturer Representative: Pharmaceuticals 100% Manufacturer: What are your main products? What are your most important materials? What are the main production methods? Example 1: Weaving cotton broad-woven fabrics 80%; Spinning cotton threads 20% Example 2: Ready- mix concrete manufacturing 40%; Precast concrete pipe manufacturing 60% Services: Describe in detail the services you provide. To whom do you provide those services? If you offer consulting, brokerage, management, or similar services, what are your major activities? Example 1: Hair cutting & styling 65%; Manicure 25%; Facials 10% Example 2: Long distance trucking, general freight, less than truckload 100% Example 3: Marketing consulting: Planning marketing strategy 60%, Sales forecasting 40% Example 4: Employee leasing company 100% (Include information on your clients nature of business.) Example 5: Lawn care 60%; Snow removal 40% Example 6: Full-service restaurant 100% Construction or Building Trade: Is the work mostly residential or nonresidential? Single or multifamily? New or remodeling? Example 1: Electrical contractor: Wiring new homes 51%; Electrical refurbishing of office buildings 49% Example 2: Fencing grazing land 20%; digging ditches for utility lines 10%; residential driveway construction (poured concrete) 70% This information is critical to determine your tax rate. Description 13b. Provide information for a contact person who has knowledge about the nature of this business. Name: Phone # Title: address (if available): Company website if available: Page 3

5 Domestic Employers, Agricultural Employers, n-profit organizations, and Political Subdivisions answer Questions 14, 15, 16, or 17. All other employers skip to the *Signature is Required* area 14. For Employers of Domestic (household) help only: Have you or will you have a total payroll of $1,000 or more during any calendar quarter? Yes If yes, what calendar quarter and year? 15. For Agricultural operations only: 15a. Have you paid or will you pay $20,000 or more in wages during any calendar quarter? Yes If yes, what calendar quarter and year? 15b. Have you had or will you have 10 or more workers for 20 weeks or more in any calendar year? Yes If yes, what calendar quarter and year? 16. For 501(c)(3) n-profit Organizations only: (You must provide a copy of your 501(c)(3) exemption letter from the IRS) Did your entire organization employ four (4) or more persons in twenty (20) weeks during any calendar year including full and part time employees? Yes If yes, what date? For Unemployment Insurance, do you wish to elect: (check only one) Liability on a tax basis Reimbursement of benefits paid to former employees If no, do you wish to have optional Unemployment Insurance Coverage? Yes 17. For Political Subdivisions only: City Town County State School District College or University Board of Education Other: For Unemployment Insurance, do you wish to elect: (check only one) Liability on a tax basis Reimbursement of benefits paid to former employees If You Are: A Corporation A Partnership A Limited Liability Company A Sole Ownership Signature is Required Who Must Sign: An Officer Authorized to sign on behalf of the corporation One Partner The Managing Member The Owner I certify this application has been examined by me and to the best of my knowledge and belief is true, correct, and complete. Signature: Name: Title: Date: Page 4

6 IF YOU ACQUIRED A BUSINESS WYOMING WORKERS' SAFETY & COMPENSATION and UNEMPLOYMENT INSURANCE TRANSFER OF EXPERIENCE RATE When a person acquires the trade, organization, business, substantially all of the assets or some or all the workforce 1 of an employer, that person shall assume the account(s), benefit experience (UI) / claims experience (WC) and tax rate(s) of the relinquishing party. 2 NOTE: A person who knowingly or with deliberate disregard of the facts or the requirements of the Wyoming Employment Security Law or the Wyoming Workers Compensation Act, violates or attempts to violate or who knowingly advises another to violate these Acts related to determining the assignment of a contribution rate shall be subject to civil and felony penalties punishable by a fine of not more than $50,000, imprisonment for not more than 5 years, or both. Certification 3 The undersigned jointly confirm and certify to the Department that ( Acquiring Party ) acquired the trade, organization, business, substantially all of the assets or some or all of the workforce of ( Relinquishing Party ) and understand that the Acquiring Party shall assume the account(s), benefits experience (UI) / claims experience (WC) and tax rate(s) of the Relinquishing Party based upon said acquisition. Acquisition Effective (date): Acquiring Party s Authorized Signature Date Relinquishing Party's Authorized Signature Date 1 The transfer of some or all of an employer s workforce shall be considered a transfer of trade or business when, as a result of the transfer, the transferring employer no longer performs trade or business with respect to the transferred workforce, and the trade or business is performed by the person or entity to whom the workforce is transferred. 2 If the relinquishing party remains in business or begins a new business, the relinquishing party shall be treated as a new employer and assigned an account(s) and tax rate(s) as such. As a new employer, the relinquishing party must submit a new, completed registration form. 3 The Department may determine a predecessor/successor relationship without Acquiring Party or Relinquishing Party signatures, based on available information and application of the statutes. Page 5